Scientific Article   |    
Venous Thrombosis After Hallux Valgus Surgery
Roman Radl, MD; Norbert Kastner, MD; Christian Aigner, MD; Horst Portugaller, MD; Herbert Schreyer, MD; Reinhard Windhager, MD
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Investigation performed at the University of Graz, Graz, Austria

Roman Radl, MD
Norbert Kastner, MD
Christian Aigner, MD
Horst Portugaller, MD
Herbert Schreyer, MD
Reinhard Windhager, MD
Departments of Orthopaedic Surgery (R.R., N.K., C.A., and R.W.) and Radiology (H.P. and H.S.), University of Graz, Auenbruggerplatz 9, 8036 Graz, Austria. E-mail address for R. Radl: roman.radl@uni-graz.at

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

J Bone Joint Surg Am, 2003 Jul 01;85(7):1204-1208
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Background: Although surgery for the treatment of hallux valgus is frequently performed, the exact rate of deep vein thrombosis following this procedure is unknown. We performed a single-center, prospective, phlebographically controlled study to quantify the rate of venous thrombosis following operative correction of hallux valgus.

Methods: Consecutive patients undergoing chevron bunionectomy for correction of hallux valgus deformity were enrolled in the study. Patients with clinical or hematological risk factors for venous thrombosis were excluded. One hundred patients with a mean age of 48.9 years were operated on and did not receive medical prophylaxis against thrombosis. All patients were assessed with phlebography at a mean of twenty-nine days postoperatively.

Results: Venous thrombosis was found in four patients (4%). The mean age of these patients (and standard deviation) was 61.7 ± 6.1 years compared with a mean age of 48.4 ± 13.9 years for the patients in whom thrombosis did not develop (p = 0.034).

Conclusions: Patients are at a low risk for venous thrombosis following surgical treatment of hallux valgus. The need for prophylaxis against thrombosis should be calculated individually for each patient according to his or her known level of risk. Routine medical prophylaxis against thrombosis might be justified for patients over the age of sixty years.

Level of Evidence: Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Roman Radl
    Posted on September 30, 2003
    Dr. Radl replies to Drs. Simon and Mass

    We thank Dr. Simon for his interesting comments regarding our article dealing with venous thrombosis following bunion surgery. In the diagnosis of deep vein thrombosis there are three methods that have been shown to be accurate in the investigation of symptomatic patients: venography; ultrasonography; and impedance plethysmography (3). However, in the detection of asymptomatic thrombosis in the calf veins the Doppler ultrasound, phleborheography and other non invasive techniques were found to be unreliable as routine surveillance tools(1,2).

    Ascending venography remains the most reliable screening modality and therefore is said to be the gold standard in the detection of venous thrombosis, but it is invasive(1). Hence, from our findings, we suggest that thrombosis screening using venograhy instead of ultrasound and phleborheography as in the study by Simon et al. might have led to a higher prevalence of detected postoperative thrombosis (5).

    Preoperative contrast studies were not performed in our series. We wanted to avoid a possible postphlebographic venous thrombosis and minimize the risk of other phlebographic related complications by performing only one invasive investigation, as the risk of DVT following minor surgery is known to be very low. Venography was performed at four weeks postoperatively to include detection of late deep vein thrombosis. Also, preoperative screening for non symptomatic DVT would possibly have resulted in the selection of a cohort that was not representative.

    In large series, 17 to 23 per cent of distal thrombi propagated to the thigh, and approximately 50 per cent of those resulted in pulmonary embolism. Multiple studies involving 100 to 200 patients each have shown that 40 to 60 per cent of all thrombi after total hip replacement, and as many as 95 per cent of those after total knee arthroplasty, involve the deep veins of the calf(1). The majority of symptomatic episodes of DVT start in the calf veins, but symptoms are uncommon until there is involvement of the proximal veins. (4).

    Although it has been stated that about half of calf thromboses resolve spontaneously within 72 hours, about one sixth extend to the proximal veins and thus increase the risk of pulmonary embolism(4). Therefore, we do not agree with Dr. Simon's assumption that calf vein thrombosis is unlikely to lead to a pulmonary embolus. Finally, the main message of our study was that there is a possible risk of deep vein thrombosis following bunion surgery. We feel that patients with obvious risk factors for DVT should receive medical DVT prophylaxis.

    1. Ciccone WJ, 2nd, Fox PS, Neumyer M, Rubens D, Parrish WM, Pellegrini VD, Jr. Ultrasound surveillance for asymptomatic deep venous thrombosis after total joint replacement. J Bone Joint Surg Am, 80(8): 1167-74., 1998. 2. Comerota AJ, Katz ML, Grossi RJ, White JV, Czeredarczuk M, Bowman G, DeSai S, Vujic I. The comparative value of noninvasive testing for diagnosis and surveillance of deep vein thrombosis. J Vasc Surg, 7(1): 40- 9, 1988. 3. Hirsh J, Hoak J. Management of deep vein thrombosis and pulmonary embolism. A statement for healthcare professionals. Council on Thrombosis (in consultation with the Council on Cardiovascular Radiology), American Heart Association. Circulation, 93(12): 2212-45., 1996. 4. Kearon C. Natural history of venous thromboembolism. Circulation, 107(23 Suppl 1): I22-30, 2003. 5. Simon MA, Mass DP, Zarins CK, Bidani N, Gudas CJ, Metz CE. The effect of a thigh tourniquet on the incidence of deep venous thrombosis after operations on the fore part of the foot. J Bone Joint Surg Am, 64(2): 188- 91, 1982.

    Michael A. Simon
    Posted on September 17, 2003
    Patients Undergoing Elective Forefoot Surgery Should Not Receive Prophylactic Anticoagulation
    The University of Chicago

    To The Editor:

    Early in our academic career we had the fortunate experience of being authors of one of the earliest prospective clinical randomized studies in orthopaedic surgery. The study was designed to determine whether the use of a thigh tourniquet influences the incidence of deep venous thrombosis(1). The results in a cohort of 117 patients who underwent elective forefoot surgery showed that no patient had a venous thrombosis. A recent study entitled Venous Thrombosis after Hallux Valgus Surgery also showed a very low rate of venous thrombosis; only 4/100 (4%) had calf vein thrombosis(2) This recent paper did not reference our article.

    Although the study design, method of detection of the thrombosis, and purpose of the two studies were different, the inclusion and exclusion criteria, study population, number of patients, type of surgical procedure, use of a thigh tourniquet, and outcomes were similar: However, in spite of their data and ours, Radl, et. al. conclude, “ because patients who have undergone hallux valgus surgery are at a certain risk for venous thrombosis and patients over sixty years of age especially may benefit from medical prophylaxis against thrombosis.”(2)

    No preoperative or baseline contrast studies were performed in the study by Radl, et.al. The four patients who had positive studies were significantly older (p=0.034); a close call considering just four patients who had a positive study. All of the positive contrast studies were only abnormal in the calf, which is unlikely to lead to a pulmonary embolus.

    Therefore, we strongly disagree with their suggestion that prophylactic anticoagulation is indicated for routine elective hallux valgus surgery, or any forefoot surgery.

    Michael A. Simon, M.D. Daniel P. Mass, M.D. The University of Chicago 5841 S. Maryland Ave.-MC 3079 Chicago, IL 60637


    1. Simon, MA, Mass DP, Zarins CK, Bidani, N, Gudas CJ, and Metz CE: The Effect of a Thigh

    Tourniquet on the Incidence of Deep Venous Thrombosis after Forefoot Surgery. J. BONE AND

    JOINT SURG., 64A:188-191, 1982.

    2. Radi R, Kastner N, Aigner C, Horst P, Schreyer H, Windhager R: Venous Thrombosis After Hallux

    Valgus Surgery. J. BONE AND JOINT SURG., 85A:1204-1209, 2003.

    Roman Radl
    Posted on August 19, 2003
    Re: Prevalance of venous thrombosis after hallux valgus surgery - is it low?

    R. Radl, and R. Windhager reply:

    We would like to thank Mr. R. Thalava for his commentary on our article. The intention of our study was to evaluate the potential risk of venous thrombosis following hallux valgus surgery. The venography, which up to know is regarded as the gold standard in the investigation of deep vein thrombosis, was performed only once to avoid a possible post-venographic thrombosis as stated in the literature after performing two or more investigations.1 In our study a venography was performed four weeks after the operative procedure with the intention to discover also late deep vein thrombosis, which is known from a number of publications.2,3,4 We agree with Mr. Thalava that the risk of postoperative thrombosis might be highest within the first postoperative week. An additional non invasive investigation like ultrasound performed one week after the surgical procedure would have probably detected more cases of thrombosis, however, this method is known to be unreliable as routine surveillance to detect asymptomatic venous thrombi in the calf.5 In the present study no symptoms indicating a venous thrombosis could be detected during the first postoperative week. Additionally, we want to emphasize that venous thrombi which degenerate in this short time period and therefore cannot be detected four weeks after the operation might not be of serious clinical relevance. Since the routine use of low-molecular weight-heparin as antithrombotic prophylaxis in hallux valgus surgery is very common in our country, the local ethics committee insisted on rigorous exclusion criteria. According to the findings of our study, patients following operative hallux valgus correction are at a certain risk of venous thrombosis. Therefore we feel that patients with obvious risk factors for venous thrombosis are at need of a medical thrombosis prophylaxis. The inclusion of patients with risk factors might have increased the number of cases with venous thrombosis.

    Advanced age is a well known clinical risk factor for developing first time venous thrombosis.6 The prevalence of thrombosis following total hip replacement or major trauma rises significantly with increasing age.7,8 However, in a population-based cohort study the total daily activity was systematically decreasing with the age.10 From these findings it is easy to speculate that the activity level might be reason for the significant age difference in the patients with and without postoperative vein thrombosis. Unfortunately, in our patients the exact postoperative activity level was not measured and therefore this issue can be only a speculation, but should be concern in further prospective studies.

    Reference List

    1. Radl, Kastner N, Aigner C, Portugaller H, Schreyer H, Windhager R. Venous thrombosis after hallux valgus surgery. J Bone Joint Surg Am. 2003;85:1204-8.

    1. Fraser JD, Anderson DR. Deep venous thrombosis: recent advances and optimal investigation with US. Radiology. 1999;211:9-24.

    2. Bergqvist D, Benoni G, Bjorgell O, Fredin H, Hedlundh U, Nicolas S, Nilsson P, Nylander G. Low-molecular-weight heparin (enoxaparin) as prophylaxis against venous thromboembolism after total hip replacement. N Engl J Med. 1996;335:696-700.

    3. Lassen MR, Borris LC, Anderson BS, et al. Efficacy and safety of prolonged thromboprophylaxis with a low molecular weight heparin (dalteparin) after total hip arthroplasty--the Danish Prolonged Prophylaxis (DaPP) Study. Thromb Res. 1998;89:281-7.

    4. Trowbridge A, Boese CK, Woodruff B, Brindley HH, Sr., Lowry WE, Spiro TE. Incidence of posthospitalization proximal deep venous thrombosis after total hip arthroplasty. A pilot study. Clin Orthop. 1994;299:203-8.

    5. Ciccone WJ 2nd, Fox PS, Neumyer M, Rubens D, Parrish WM, Pellegrini VD Jr. Ultrasound surveillance for asymptomatic deep venous thrombosis after total joint replacement. J Bone Joint Surg Am. 1998;80:1167-74.

    6. White R. The Epidemiology of Venous Thromboembolism Circulation. 2003 Jun 17;107(23 Suppl 1):I4-8.

    7. Sikorski, Hampson WG, Staddon GE. The natural history and aetiology of deep vein thrombosis after total hip replacement. J Bone Joint Surg Br. 1981;63:171-7.

    8. Stannard JP, Riley RS, McClenney MD, Lopez-Ben RR, Volgas DA, Alonso JE.Mechanical prophylaxis against deep-vein thrombosis after pelvic and acetabular fractures. J Bone Joint Surg Am. 2001 Jul;83:1047-51.

    9. Norman A, Bellocco R, Vaida F, Wolk A. Total physical activity in relation to age, body mass, health and other factors in a cohort of Swedish men. Int J Obes Relat Metab Disord. 2002 May;26(5):670- 5.

    Ramesh Thalava
    Posted on August 05, 2003
    Prevalance of venous thrombosis after hallux valgus surgery - is it low?
    Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom

    Dear Editor,

    I read the article on venous thrombosis after hallux valgus surgery (Radl et al., 2003) with interest. The authors have conducted a well planned study. It is reassuring to note the low prevalance rate of venous thrombosis at four weeks after hallux valgus surgery.

    I feel that a single investigation performed four weeks after the surgery may not have accurately quantified the true incidence of venous thrombosis. The authors in their discussion have clearly stated that most of the thrombi form in the first post operative week and supported it with a reference (Sikorski et al., 1981). Perhaps a non invasive investigation in the first week after surgery might have diagnosed more cases of venous thrombi.

    The study suggests a significant association between venous thrombosis and the age of the patient. Noting the inclusion and exclusion criteria, a relatively risk free population has been selected for the study. Can the authors explain the reason for the significant age dependent increase in the venous thrombosis that was noted in their study.

    Reference List

    1. Radl, Kastner N, Aigner C, Portugaller H, Schreyer H, Windhager R. Venous thrombosis after hallux valgus surgery. J.Bone Joint Surg.Am. 2003; 85-A:1204-1208

    2. Sikorski, Hampson WG, Staddon GE. The natural history and aetiology of deep vein thrombosis after total hip replacement. J.Bone Joint Surg.Br. 1981; 63-B:171-177

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